IASHEP Voluntary Surrender Form

Per the International Association of Safety, Health & Environmental Professionals (IASHEP)policy, an IASHEP professional credential holder agrees to voluntarily surrender theircertification under the following terms.The Diplomate:1. Must submit this form prior to expiration of their IASHEP certification. Failure tosubmit this form prior to voluntary surrendering their IASHEP professional credential willcause the IASHEP professional credential holder to be listed as “DECERTIFIED”.2. Cannot be engaged in an unresolved IASHEP ethics case.3. Relinquishes their International Association of Safety, Health & EnvironmentalProfessionals (IASHEP) certification but is not restricted from practicing in theiroccupational field.4. Can no longer use the IASHEP certification designation except when also referencingthe years of certification, e.g., Certified Safety, Health & environmental Professional(CSHET), 2014-2019.5. Can no longer use the IASHEP embossing seal or stamp for any professional activity.6. Is relieved of certification maintenance requirements and fees for the VoluntarySurrender Professional Credential.7. Will be listed on the IASHEP website as a Former Professional Credential Holder8. For reactivation rules, see the IASHEP website under forms. 9. Will be subject to IASHEP ethics case provisions if found to be in violation of thisagreement’s terms. No unresolved ethics issues and paid up on fees.IASHEP Professional Credential being voluntary surrendered i.e. (CEHSP)__________________________________________________________________Reason for Voluntary Surrendering IASHEP professional credential i.e Obtained higherlevel IASHEP professional credential, Retiring, not working in that field etc.____________________________________________________________________________________________________________________________________________________________________________________________________________Name: ______________________________________________________________Mailing Address:City _____________________________________________State: _________________________________________________________Zip Code:_____________________________________________________________________________________________________________________Phone Number: __________________________________________________Email Address: __________________________________________________Voluntary surrender takes effect after IASHEP acknowledgment of the VoluntarySurrender form. I have reviewed and accept the policy and terms as stated above:Signature: ________________________________________________Date:____________________________________________________